Necrosis and renal impairment

Patients with advanced diabetic nephropathy or end-

Fig. 6.9 A small split in dry skin on the border of the foot of a patient in end-stage renal failure treated with haemodialysis is becoming necrotic.

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stage renal failure have an increased propensity to develop necrosis. Most have anaemia, neuropathy (which may be aggravated by uraemia) and arterial calcification. In addition, the atherosclerotic process is accelerated. The reasons for this propensity of diabetic renal patients to develop necrosis are not entirely clear.

Necrosis can occur in diabetic renal patients with palpable pulses in the absence of severe peripheral arterial disease and in the absence of infection. An apparently small and trivial trauma such as a small split in dry skin (Fig. 6.9) or a tight nail sulcus will frequently lead to necrosis which then spreads (Fig. 6.10). Necrotic lesions often become rapidly infected in diabetic patients with renal failure.

Traumatic injuries are very common in diabetic patients in end-stage renal failure (Fig. 6.11): this may be because the soft tissues of the foot are more easily damaged in end-stage renal failure, or because patients with the heavy burden of managing to cope with diabetes and renal problems become more careless about looking after their feet.

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